Soap Notes

So the question is how many LMT's actually use soap notes in there personal practice (not employees).....Do you use soap notes for every client that walks in your door? Or do you only do notes on the clients that have a medical issue, or a sports injury and skip the notes on the ones that are just there for fluff and buff? Let the chatter begin and let me know where you stand on this.

Replies to This Discussion

I do a soap note for each client at each treatment. If a client is brand new I use a long version and shorter versions for subsequent visits. If a client is there for relaxation only, I still use a soap note chart, but simply state the the TX was relaxation massage. I also collect a medical intake for each client I work with and ask that they fill a new one out if theirs is older than 3 years.

What I don't really understand is why wouldn't you, as a practisioner, want to cover you own a--, not to mention that of a possible employer. How else are we to prove without a shadow of a doubt, to a courtroom tied up in legal debate that not only didn we follow what the doctor had prescribed. adjusting modalities as we went. customizing per client what works best for their body? I assure you, if you are going to be taking insurance claims, you will have to soap them up in order to get paid.I could be wrong, but isn't the law?Susan G. Salvo said:

Wow Marissa,

You made a very profound statement.

When working on the third edition of my textbook, Massage Therapy: Principles and Practice, I found most therapists were taught SOAP but, over time, stopped using them. Rather than criticize these therapists, I wanted to dive deeper into the issue and understand why. Most reasons boiled down to what they perceived as a lack of usefulness in their practice.

When I came across a therapist who did use SOAP, it was usually because the state or their employer required them and they did not know any other method of client documentation.

This is interesting.

If what we are teaching students/therapists is not withstanding the test of time, something’s wrong (and it probably not the therapists).

So I began to ask therapists what they needed to know to provide safe targeted client-centered sessions. What they told me time and time again was:

1) What did the client want (purpose or P)2) Does the client have any pain (pain or second P)3) Does the client have any allergies to topical agents or skin rashes (allergies or skin conditions: A)4) A little about the client’s lifestyle such as occupation, level of physical activity, level of stress, and past massage experience (lifestyle or L)5) Medical history which includes use of meds for disease management (medical history or M)

After gathering info on these assessment domains (PPALM) from the client intake form or client interview, the therapist can now formulate a client-centered treatment plan.

But is SOAP the only format? Is SOAP the best format? I agree that treatment notes are important. What I don't understand is the value of separating subjective and objective info? If the info is important, use it! I see more value in assessment domains that help therapists obtain information used to formulate treatments that help clients reach their therapeutic goals -- and to document the entire process, including reassessment. Which SOAP does NOT do, but SOAPIER notes do. Just saying…

kristi marco said:

What I don't really understand is why wouldn't you, as a practisioner, want to cover you own a--, not to mention that of a possible employer. How else are we to prove without a shadow of a doubt, to a courtroom tied up in legal debate that not only didn we follow what the doctor had prescribed. adjusting modalities as we went. customizing per client what works best for their body? I assure you, if you are going to be taking insurance claims, you will have to soap them up in order to get paid.I could be wrong, but isn't the law?Susan G. Salvo said:

Wow Marissa,

You made a very profound statement.

When working on the third edition of my textbook, Massage Therapy: Principles and Practice, I found most therapists were taught SOAP but, over time, stopped using them. Rather than criticize these therapists, I wanted to dive deeper into the issue and understand why. Most reasons boiled down to what they perceived as a lack of usefulness in their practice.

When I came across a therapist who did use SOAP, it was usually because the state or their employer required them and they did not know any other method of client documentation.

This is interesting.

If what we are teaching students/therapists is not withstanding the test of time, something’s wrong (and it probably not the therapists).

So I began to ask therapists what they needed to know to provide safe targeted client-centered sessions. What they told me time and time again was:

1) What did the client want (purpose or P)2) Does the client have any pain (pain or second P)3) Does the client have any allergies to topical agents or skin rashes (allergies or skin conditions: A)4) A little about the client’s lifestyle such as occupation, level of physical activity, level of stress, and past massage experience (lifestyle or L)5) Medical history which includes use of meds for disease management (medical history or M)

After gathering info on these assessment domains (PPALM) from the client intake form or client interview, the therapist can now formulate a client-centered treatment plan.

I try to use SOAP notes on everyone because you just never know when you may see them again. I learned my lesson a number of years ago when a friend who had come for massage for a few years was in an MVA. She wanted massage treatments and her insurance company wanted all of her previous Treatment notes - though she came for relaxation the notes were not like I would have liked but detailed enough to send them what they needed. Had I not kept even the scantiest of notes I would have been in a real pickle.

I use SOAP's but not all the time. For first time clients I always do an intake and SOAP. If it has been 1 year or more I do a new intake and SOAP again. Most of my clients are regular's who come in frequently so I do a chart when something has changed or something is going on...I keep record of every single appt in a program called Customer Pro and write notes in there too. I keep better track now than ever before because a few years back a client needed records of every appointment she had with me for a workman's comp case. She wanted to get reimbursed for the massages she paid for. I was glad I had them...

I do Soap notes for every client even friends every visit , you don't know when it will be needed . I did a free massage on a friend , a few months later I needed it to help her determine how much injury she had sustained in an accident . Her Doctor and lawyer have copies and it was a very valuable peace of information

Also if you have regular clients you can look back and see if there is any changes physically and topically . You may notice something even a spouse doesn't. Soap notes are very valuable.

How many LMT's that use soap notes do so electronically? I'm asking because we just launched SOAP Vault, a web-based software for therapists to manage their patients and soap notes, and we'd like any feed back therapists can give:)

As long as there is an internet connection, you can log into your clinic from anywhere in the world. Use the built in calendar to check or schedule your appointments, or enable on-line booking for your patients. Anywhere, anytime.